• Snake-bites are well-known medical

emergencies in many parts of the world,

especially in rural areas.
• Agricultural workers and children are the
most affected.
• The incidence of snake-bite mortality is
particularly high in South Asia.
 Prevention
• By understanding something about the habits of
snakes, simple precautions can be adopted to reduce
the chance of encounters and consequently bites.
• One must know the local snakes, the sort of places
where they prefer to live and hide, the time of year and
time of day or night and the kind of weather when they
are most likely to be actively out and about.
• Many species are mainly nocturnal (night hunters) e.g.
kraits, but other species are mainly diurnal (day-time
hunters)
How to identify venomous snakes?
• Unfortunately, there is no simple rule for
identifying a dangerous venomous snake.
Some harmless snakes have evolved to look
almost identical to venomous ones.
 Snake venoms
• Venom composition More than 90% of snake venom (dry
weight) is protein.
• Each venom contains more than a hundred different
proteins: enzymes, non-enzymatic polypeptide toxins, and
non-toxic proteins
• Venom enzymes :These include digestive hydrolases,
hyaluronidase, and activators or inactivators of
physiological processes, such as kininogenase. Most
venoms contain l-amino acid oxidase, phosphomono- and
diesterases, 5’-nucleotidase, DNAase, NAD-nucleosidase,
phospholipase A2 and peptidases.
 Quantity of venom injected at a bite,

• This is very variable, depending on the species

and size of the snake, the mechanical efficiency
of the bite, whether one or two fangs penetrated
the skin and whether there were repeated
strikes.
• Bites by small snakes should not be ignored or
dismissed. They should be taken just as
seriously as bites by large snakes of the same
species.
 Symptoms and signs of snake-bite
When venom has not been injected
• Some people who are bitten by snakes or suspect or imagine that they have
been bitten, may develop quite striking symptoms and signs even when no
venom has been injected.
• This results from an understandable fear of the consequences of a real
venomous bite.
• Anxious people may over-breathe so that they develop pins and needles of the
extremities, stiffness or tetany of their hands and feet and dizziness.
• Others may develop vasovagal shock after the bite or suspected bite-faintness
and collapse with profound slowing of the heart. Others may become highly
agitated and irrational and may develop a wide range of misleading
symptoms.
• Blood pressure and pulse rate may increase and there may be sweating and
trembling
• Another source of symptoms and signs not caused by
snake venom is first aid and traditional treatments (Harris
et al., 2010).
• Constricting bands or tourniquets may cause pain,
swelling and congestion that suggest local envenoming.
• Ingested herbal remedies may cause vomiting.
• Instillation of irritant plant juices into the eyes may cause
conjunctivitis.
• Forcible insufflation of oils into the respiratory tract may
lead to aspiration pneumonia, bronchospasm, ruptured ear
drums and pneumothorax.
• Incisions, cauterization, immersion in scalding liquid and
heating over a fire can result in devastating injuries
 Symptoms when vein is injected
• There may be increasing local pain which may be
burning, bursting or throbbing at the site of the bite.
• Patient may gradually develop local swelling that may
extend proximally.
• There may be tender lymphadenopathy which is
usually in inguinal or femoral areas, following bites in
the lower limb areas following bites in the upper limb.
• Local symptoms are more prominent in Viper bites
whereas Kraits, sea snakes and Philippine cobra bites
may be virtually painless with minimal local swelling.
• Patients can have general nonspecific
symptoms like nausea, vomiting, malaise,
abdominal pain, weakness and drowsiness
• Specific features like visual disturbances,
dizziness, faintness, collapse, shock,
hypotension, arrhythmias, pulmonary edema
and conjunctival chemosis are suggestive of
cardiovascular involvements which are
specially seen in Viperidae bite.
• Manifestations similar to bleeding and clotting
disorders are also seen in Viperidae bite
• Patients can also develop spontaneous bleeding from gums,
nose, conjunctiva, gastrointestinal tract, urinary bladder,
lungs, retina, uterus and vagina.
• Intracranial hemorrhage must be suspected in patients who
have lateralizing neurological signs or coma.
• Acute and chronic pituitary or adrenal insufficiency can be
caused by Viper bite.
• Neurological symptoms are seen in Elapidae and Russell's
viper bite. These patients may have drowsiness, paraesthesia,
loss of taste and smell, ptosis, diplopia due to external
ophthalmoplegia, facial paralysis, inability to open the
mouth, inability to protrude the tongue from the mouth, nasal
speech, nasal regurgitation, and paralysis of the muscles of
the hands
• Rhabdomyolysis is seen in patients bitten by sea snakes,
some krait species like Bungarus niger, B. candidus and,
western Russell's viper- Daboia russelii.
• These patients will have generalized pain, stiffness and
tenderness of muscles, trismus and myoglobinuria.
• The patients may die of hyperkalaemia, cardiac arrest, acute
kidney injury.
• Renal involvement is seen Viperidae and sea snakes. They
may present with loin pain, haematuria, haemoglobinuria,
myoglobinuria, oliguria and features of uremia.
• Some patient can develop long term complications after
snake-bite like chronic ulceration, contractures, arthritis,
osteomyelitis, limb amputation and malignant
transformation of skin ulcers
 TREATMENT
• Reassure the victim who may be very anxious and
immobilize the patient in a comfortable position.
• Affected limb should be kept below the level of the heart.
Any movement of the body increases absorption of venom
into the bloodstream and lymphatic.
• First-aid treatment is carried out immediately by the
patients himself after the bite before reaching the hospital
with the aim to retard systemic absorption of venom,
control distress, preserve life and prevent complications.
• Consider pressure-immobilization or pressure pad where
facilities are available.
• But most of the traditional first-aid methods like making local
incisions, sucking the venom out of the wound, tourniquets
around the limb, application of chemicals, herbs or ice pack
have been proved to be useless or sometimes even dangerous.
• Tight tourniquets proximal to bite are not recommended as
this method can be extremely painful and dangerous.
• If the tourniquet was left for 40 minutes, the limb may
develop is gangrene.
• Any interference with the bite wound like incisions, rubbing,
vigorous cleaning, massage, application of herbs or chemicals
are strongly discouraged as this may introduce infection,
increase absorption of the venom and increase local bleeding.
• A suitable safe transport must be made available to shift the
patient to a proper treat
• Immediate transportation of the victim to the nearest health
centre where anti-snake venom serum is available is the
most important first aid measure.
• During transfer support the airway and breathing,
administer oxygen and establish of intravenous line in the
unaffected limb.
• A stretcher, bicycle, motorbike, cart, horse, motor vehicle,
train or boat can be used.
• Transport by motorcycle or other motor vehicles has been
found effective especially in rural areas and is the key to
save time
• Lack of transport facilities and inability to
afford transportation leads to delay or inability
in seeking medical treatment in a large number
of the victims which may lead to respiratory
failure and death.
• With the passage of time venom gets bound to
the tissues and thus cannot be neutralized by
anti-snake venom
• The clinical syndromic diagnosis should be made and
the victim should be treated empirically according to
the suspected species.
• Once patient reaches the hospital airway , respiratory
movements, arterial pulse and level of consciousness
must be checked immediately and dealt appropriately.
• During initial evaluation, base-line circumferential
measurements at several points above and below the
site of the bite should be documented.
• Measurements should be repeated and documented
every 15 to 20 minutes until local progression of
swelling subsides.
• If possible monitoring in an intensive care unit
is recommended for all patients treated with
antivenom.
• Base-line laboratory studies should include a
complete blood count with platelet count,
coagulation profile, measurement of fibrin
degradation products, electrolytes, blood urea
nitrogen, and serum creatinine, and urinalysis.
• Laboratory studies should be repeated after
each infusion of antivenom.
• Other tests like creatine kinase, blood typing with
cross-matching, chest radiography, and
electrocardiography can be done, if required.
• Patients with neurotoxic venoming may present
with terminal respiratory failure due to paralysis of
the respiratory muscles and may require
endotracheal intubation and ventilatory support.
• Some patients may present with hypotension and
shock. It may be a result of anaphylaxis induced by
the venom, direct cardiovascular effects of the
venom and release of inflammatory vasoactive
mediators or due to profuse bleeding
 CONCLUSION
• Snake-bite is still a major problem in developing countries like Nepal,
causing significant morbidity and mortality.
• There is gross disparity in the management and outcome of snakebite in
different hospitals.
• There is a great need to improve in existing health care conditions for
effective management of snake-bite.
• It requires training of the personnel engaged in the emergency health care
management, development of national guidelines based on the clinical
trials, improving the distribution and easy availability of antivenom.
• Efforts are needed to develop studies on the epidemiology of snake-bite
and education of the population at risk.
• Development and manufacturing of antisnake venom for local snakes is
highly recommended.